By Christopher Guadagnino, Ph.D..
Interview with John Wasson, MD.
John Wasson, M.D., is director of Dartmouth Medical School’s Center for the Aging, and research director for Dartmouth Northern New England Primary Care Research Network.
PND: What is patient-centered collaborative care, and why is it important for physicians to practice in this way?
JW: Health care produces jargon. The term “patient-centered” care seems to have its origins as a reaction to paternalistic “doctor-centered” health services. “Collaborative care” results when doctors and members of the “health care team” actively engage patients in “evidence-based” decision-making and management based on what matters to the patients. Patients should become better “self-care managers” as a result of collaborative care. Collaborative care almost synonymous with a “productive interaction” is associated with improved patient outcomes. Regardless of jargon, patients who experience the best health care possible the best “patient-centered collaborative care” possible should strongly agree that they are receiving “exactly the care they want and need exactly when and how they want and need it.” Only about 25 percent of adult Americans strongly agree that they have received “patient-centered collaborative care” defined in this way. We have a long way to go.
We are trained to focus on what is the matter with the human body and mind that’s our bioclinical and pathological training. But, of course, what matters to the owner of the body and the mind may not be congruent with “what is the matter with it,” for a number of reasons. For example, an overweight, pre-diabetic may never lose weight until the emotional issues leading to the overeating are dealt with. We’re often unaware of their emotional issues. In fact, nationally, only about half of diabetics with emotional problems report that their doctors are aware of them. Until we’re aware, we may not understand that the patient lacks confidence in losing weight. Only about 40 percent of diabetics who are overweight have confidence in managing their problem; 60 percent don’t. Until that lack of confidence is overcome, they’re not going to be able to move ahead.
Being patient-centered requires us to understand both, “what’s the matter with the patient” in this case, diabetic and being overweight and “what matters to the patient,” as well. If we do that, then we’re on the same page with them. The collaborative side of it means that, once we are on the same page, we know how to give our patients the best information and support they need to both better manage what matters to them and what is the matter with them. Why is it important? Because the literature, and common sense, indicates that when patients attain patient-centered collaborative care their outcomes are much better than patients not receiving such care. It’s good for patients and good for physicians who are increasingly being asked, and paid, for improved outcomes.
PND: As long as physicians are providing the best, scientifically validated care, why do they need to be concerned with patient-centered and collaborative care?
JW: Merely telling someone they have a scientifically validated risk factor, such as a high BMI, or prescribing insulin for validated hyperglycemia will not result in as good an outcome, in terms of diabetic control and weight reduction, as providing the information and insulin in a patient-centered collaborative context, so that the patient can become confident in managing both the blood sugar and weight. You can’t get all the way just by handing out scientifically validated pills, for example, if the patient has other issues and won’t take the pills. Maybe they’re under a huge amount of stress at home or on their job, they’re somewhat depressed and emotionally wrecked, and so their diabetes control is something that, frankly, is not on their to-do list right now. There may also be functional problems, for example, the patient who has significant pain that you’re unaware of while you’re encouraging them to be more active because they happen to have coronary artery disease. A large managed care company in New York State asked me to consult with them because a number of women were doing badly in their asthma management and they didn’t understand why. We found that a third of the women were in domestic abuse situations. A woman who is in that type of situation, I don’t think is going to be focused quite as well on her inhaler use as someone who isn’t.
PND: Is the fundamental issue patient compliance?
JW: Compliance is about the worst word you can think of. That’s our way of, in essence, blaming the patient. No, the issue is that the patient may have other concerns that matter more to them and it’s manifested in them not taking the pills. Our job is not just to hand out pills, you can get a machine to do that, but to help in the behavioral and other types of therapies needed to help patients maximally manage whatever problems they have. Now clearly, in an acute setting like an emergency room, the concept of patient-centered collaborative care is silly. If someone is bleeding from an aortic aneurysm, we’re not going to sit there and ask ourselves what is it that might matter to the patient. But, as you move away from those acute situations, on which our health care was built and a lot of our training takes place, and move to the real work of most clinical practices, if you don’t engage the patient and help them in a collaborative way, and you’re not on the same page with them, you’e just not going to have good results.
There is seldom a best, scientifically validated approach for a patient because most patients seldom have just one thing wrong with them for which there is one perfectly validated treatment. Maximally effective treatment requires us to balance what we know scientifically, what we don’t know scientifically, and what the informed patient would want and benefit from. To manage “what is the matter” it is important to know “what matters” to our patients.
PND: What data are there to show the benefits of this approach?
JW: There is a large amount of information from controlled trials and uncontrolled observations that patient-centered collaborative care improves outcomes. Any reader can Google patient self-management and find numerous articles in leading journals. Let me share a recent example from a controlled trial we performed with a group of patients who use much more health care than most: patients with pain and psychosocial issues. About a third of Americans who visit clinical practices have some form of persistent pain, and about 40 percent of these people will also have psychosocial problems. Compared to Americans not reporting pain or psychosocial problems, these patients have a lot of morbidity and use of clinical services. About 10 percent of typical adult ambulatory patients overall fit this category, but physicians are aware of the underlying pain and psychosocial component of the patient’s other medical illnesses and problems only about half of the time.
So, we did two things in this study. We first used a simple survey to identify about 1,200 patients with pain and psychosocial problems in primary care practices. The tool available at www.HowsYourHealth.org provided them with individualized feedback and also created a summary report for their doctor. Then, we offered them phone coaching, so that they could improve their problem-solving skills. At the end of a year, they were much, much better than patients treated in the usual way. “What matters” and “what is the matter” were both assessed, the clinician and the patient could be on the same page, and with some collaborative assistance the patient was supported in self-management. The outcomes were incredibly positive: the typical patient had about a 40 percent reduction in pain a year later, just merely having the assessment and three brief phone calls. There’s also a huge literature, a lot of which focuses on diabetes management by managed care companies, documenting that by paying attention to patient self-management needs they could easily pay for any program cost many times over and improve patient outcomes.
PND: What are specific ways in which this approach can be implemented and adapted to various types of patients?
JW: There is no a single thing a doctor, an office practice or a health care system can do to guarantee patient-centered collaborative care. Many things must be done well. However, there are a few simple principles and techniques that can guide us. Patient-centered collaborative care means that we know how to provide and actually can provide our patients with the best information and support they need to better manage both what matters and what is the matter with them. We can help them become confident with self-management and problem-solving. Patient confidence is an important “final common pathway,” and we can segment populations of patients based on their confidence, understanding that there are reliable, well-tested methods to better manage patient so segmented, and understanding that our current practice processes and workforce are often poorly aligned to provide this care. There are some simple tools such as “CARE Vital Signs” and www.HowsYourHealth.org that are easy to fit into everyday practice to help assess what is the matter.
The ultimate way you can find out what to do with patients is to find out how confident they are that’s the key question. Stratify your patients by confidence with self-management, regardless of disease. When a patient says they are very confident (about 30 to 50 percent of typical patients rate themselves a “9 or 10” on a 10-point scale) they usually do not need a lot of extra support. Take advantage of technology that supports assessment, feedback and problem-solving offered free at www.HowsYourHealth.org. When they are not very confident you will need to make sure these tools, or paper versions of them, are used to increase confidence. For example, Care South Carolina cares for a lot of low literacy, sick patients. Over a six month period they moved their patient with hypertension only 40 percent of whom were confident in self-management to over 90 percent confidence just by being persistent. And guess what happened to the patients blood pressure control? It got better, of course.
Collaboration is across the entire office practice. Once you start thinking about this, you get a population mindset how to deal with groups of patients and you start reorganizing the way your workforce operates. You may start doing things like group visits for low-confidence patients, you might have medical assistants doing much more coaching of patients on the issues that matter to them, so that they could become more confident.
PND: What are the major obstacles to this approach to care, and how can they be overcome?
JW: The first obstacle we all face is the way our practices are organized now. They’re pretty much designed to treat each patient individually, and not think across groups of patients, so we don’t get the economies of thinking across populations. Another obstacle is our mindset and the payment mechanism that makes us just think of each patient as a potential RVU. The whole term, “patient-centered collaborative care” is a turnoff. It’s jargon. The challenge is to get beyond that and look at the principles behind it. If you’re thinking of pay-for-performance, you’re only going to get as good performance as possible when the patient is good at self-management. The Care South Carolina example illustrates that: if you’re going to get paid for good hypertensive management in a low-income population and you don’t deal with their confidence with self-management, you’re not going to get the results and you’re not going to get paid as much. That means you’ve got to be on their page. You’ve got to know what matters and what’s the matter with them. The final problem with mindset is the old one: “When you’re up to your neck in alligators, it’s hard to remember that you were there to drain the swamp.” Most clinicians are so stressed with RVU-itis on a case-by-case individual patient basis, that they can’t step back and think about ways to manage their patients as populations by level of confidence and about what tools and techniques they can use to identify confidence and manage it.
The point of all this is that it doesn’t matter about the disease. What matters more is the process that you deal with across all diseases and conditions: find out what are the major issues that matter to your patients, find out how confident they are, stratify them into groups: those who are confident and those who aren’t, and take advantage of the technologic tools that I’ve mentioned for both groups, but be much more persistent with those who have a lot of psychosocial or low-confidence issues. One of the tools, CARE Vital Signs, adds questions to the patient interaction: for example, one question about their emotional well-being, one question about their confidence with self-management, perhaps another question about their pain. I urge all readers to look at the “Cool Tools” at IdealMicropractice.org or IdealMissouriPractice.org. These websites are used by clinicians across the country who are now learning how to provide patient-centered collaborative care. These clinicians are also focusing on ways to reduce practice overhead and waste.
PND: How dependent is this approach on technology?
JW: Technology can be helpful because it is often much more eliable at assessing and providing predictable, effective feedback to patients and clinicians. However, it is not necessary. Care South Carolina, for example, has taken the key parts of the web-based resources for problem-solving and had their medical assistants use them to improve patient confidence. Another physician used a high school student to coach her patients in problem-solving, and the patient did not have to touch the computer. Paper, or reusable plastic CARE Vital Signs, gets a lot of the way toward patient-centered collaborative care without a computer.